Low FODMAP diet – use in endometriosis
The low-FODMAP diet is one of the most commonly used diets for people with gastrointestinal disorders. Many women with endometriosis also try it, seeking relief from the symptoms associated with the condition. The low-FODMAP diet can indeed be effective, but only in specific cases and when implemented correctly. It's not easy, so before starting it, it's worth understanding what it actually involves, how to implement it, and what to look for. You'll read about that in this article.
What is the low fodmap diet?
To understand what the low FODMAP diet is, we first need to break it down. FODMAP is an abbreviation for:
- F – fermentable,
- O – oligosaccharides,
- D – disaccharides,
- M – monosaccharides,
- A – and,
- P – polyols.
In Polish, they mean "fermentable oligosaccharides, disaccharides, monosaccharides, and polyols." This is a very broad group of compounds classified as carbohydrates and polyols that occur naturally in food. What they have in common is their impact on the functioning of the gastrointestinal tract.
- Fodmaps are osmotically active compounds. This means they increase the amount of water in the intestinal lumen. This, in turn, can contribute to diarrhea and the unpleasant feeling of bloating in the intestines.
- Fodmaps also undergo fermentation in the intestines, which is associated with the production of gases such as hydrogen, methane and carbon dioxide. Their excess in the digestive tract causes bloating, discomfort and abdominal pain.
High consumption of foods high in FODMAPs can therefore contribute to gastrointestinal problems. It might seem that eliminating them improves digestive comfort, alleviates symptoms , and is sufficient to address gastrointestinal issues. Unfortunately, the reality is somewhat more complicated. First of all, the list of foods high in FODMAPs is very long and includes many healthy, nutritious products that are an important element of a well-balanced, anti-inflammatory diet. A low FODMAP diet is therefore very eliminative, increasing the risk of nutritional deficiencies and their consequences . Furthermore, FODMAPs also have their benefits: they provide food for intestinal bacteria, support the health and diversity of intestinal microflora, and are a substrate for the production of anti-inflammatory short-chain fatty acids, including butyric acid.
A low-FODMAP diet is therefore recommended, even necessary, for some gastrointestinal disorders. However, it is not intended for long-term use due to the risk of complications. Eliminating FODMAPs from your diet may improve daily digestive comfort, but in the long term, it may contribute to other health problems. It's best to discuss any transition to a low-FODMAP diet with a doctor and dietitian, who will help develop a personalized, safe, and effective management plan. If you struggle with abdominal pain, bloating, constipation, or diarrhea and are considering a low-FODMAP diet, or are simply looking for ways to improve your health and well-being, schedule a dietary consultation with one of our specialists.
When to use the low fodmap diet?
The primary indication for a low-FODMAP diet is irritable bowel syndrome (IBS). Its effectiveness is estimated at 50-86%. It may also be considered for SIBO , especially if it coexists with IBS . While research on the use and effectiveness of the low-FODMAP diet for SIBO is limited, many patients experience significant improvement after implementing it.
How does the low-FODMAP diet work in endometriosis? It's worth emphasizing that the low-FODMAP diet doesn't directly affect the course of endometriosis , but it can support the treatment of co-occurring conditions such as IBS and SIBO. This improves patients' daily comfort and positively impacts the functioning of the gastrointestinal tract, which is essential for proper digestion and nutrient absorption.
At this point, I'd also like to address the topic of endobelly, or abdominal bloating that occurs before and during menstruation. Many women experiencing this problem decide to adopt a low-FODMAP diet, hoping it will bring relief. Unfortunately, this isn't always the case. Endobelly is associated with endometriosis and hormonal changes that occur during certain phases of the cycle. If IBS and SIBO aren't present, the low-FODMAP diet isn't appropriate and may lead to unnecessary dietary restrictions, stress, and nutritional deficiencies. Therefore, remember to consult a specialist about all symptoms. Understanding their causes will help you plan appropriate treatment.
Low Fodmap Diet Principles
The main principle of the low-FODMAP diet is to limit fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. It is divided into three stages.
- phase 1This is the elimination phase. It involves eliminating all foods high in FODMAPs for approximately 4-7 weeks. For some patients with moderate symptoms, a so-called gentle-FODMAP protocol is used. We don't eliminate all sources of FODMAPs, but only those that have previously exacerbated symptoms. Its implementation should be preceded by a consultation with a dietitian, who will help identify problematic foods.
- Phase 2. This is the reintroduction phase. We reintroduce high-FODMAP foods into the diet and test individual tolerance. This is often the most difficult phase, as it requires intense mindfulness and self-observation. It typically lasts 6-8 weeks.
- Phase3. This final stage, called the individualization stage, involves composing a diet that is as varied as possible and eliminates only those foods that exacerbate symptoms. It is intended for long-term use.
As you can see, the low-FODMAP diet is quite demanding. Simply eliminating certain foods isn't enough. Self-observation, attentiveness to bodily symptoms, and a highly personalized approach are crucial. Furthermore, the lack of results from the low-FODMAP diet is most often due to incorrect implementation. Patients often come to me after several attempts on their own—as you can probably imagine, this causes them a lot of unnecessary stress and frustration. Treating gastrointestinal problems in endometriosis is a difficult process, so it's worth seeking the support of specialists, who can make the process shorter and more effective.
What not to eat on a low fodmap diet?
You already know that the low-FODMAP diet is an elimination diet. Now let's look at which foods should be limited. FODMAPs include fructose (a monosaccharide), lactose (a disaccharide), fructans and galactooligosaccharides (oligosaccharides), as well as xylitol, sorbitol, mannitol, and maltitol (polyols). Their main sources include fruits, vegetables, legumes, some nuts, dairy products, grain products, and highly processed foods. The table below provides examples of foods from each of these groups that contain high levels of FODMAPs.
| Food product group | Examples of foods high in FODMAP |
| Fruits | Apples, pears, mangoes, nectarines, peaches, watermelon, plums, cherries, sour cherries |
| Vegetables | Onion, garlic, leek, chicory, cauliflower, broccoli, cabbage, asparagus, artichokes, soy and soft tofu, lentils, peas, broad beans, beans, chickpeas |
| Dairy | Cow's milk, cottage cheese, yogurt, cream and sour cream, ricotta, mascarpone |
| Nuts | Pistachios, cashews |
| Grain products | Wheat, rye and barley products |
| Sweets and snacks | Beverages and sweets with xylitol, sorbitol and mannitol, honey, agave syrup |
These foods can exacerbate gastrointestinal symptoms such as abdominal pain, bloating, and diarrhea. The first stage of dietary therapy usually requires eliminating all of them for approximately four weeks.
What to eat on a low fodmap diet?
Despite its limitations, a low-FODMAP diet should still be diverse, healthy, and minimally processed. The table below lists foods that are low in FODMAPs and can be included in your meals even during the elimination phase.
| Food product group | Examples of foods high in FODMAP |
| Fruits | Blueberries, raspberries, strawberries, pineapple, melon, kiwi, tangerines, oranges, grapefruits, bananas, passion fruit |
| Vegetables | Lettuce, rocket, corn salad, spinach, parsley, carrots, potatoes, cucumbers, zucchini, tomatoes, eggplant, red pepper, sweet potato |
| Dairy | Milk and lactose-free dairy products, feta cheese, yellow cheeses |
| Nuts | Walnuts, macadamia nuts, chia seeds, pumpkin seeds |
| Grain products | Rice, rice pasta, quinoa, buckwheat, buckwheat flakes, buckwheat groats, corn, corn pasta, corn flour, corn waffles, spelt sourdough bread |
| Sweets and snacks | Maple syrup, sugar |
The products mentioned are considered safe and rarely cause gastrointestinal distress. However, it's important to pay attention to the quantities. For example, 60g of strawberries contains little fructose and is considered low-FODMAP. However, doubling this amount and eating 100-120g of strawberries would constitute a high-FODMAP portion. Therefore, even with permitted products, quantity and moderate consumption are important.
Low FODMAP Diet Recommendations
The low FODMAP diet isn't just about eliminating certain foods. Eating regularly and hygienically is also crucial, as is getting enough sleep, physical activity, and avoiding stimulants. The most important recommendations on the low FODMAP diet are:
- Eating calmly, slowly and chewing food thoroughly. Avoid eating in a hurry or in chaotic conditions. Mindful Eating for Endometriosis is the key to minimizing gastrointestinal symptoms and unnecessary stress.
- Eating regularly. Try to plan fixed, repeatable meal times.
- Limit caffeine, alcohol and carbonated drinks. Instead, choose still water and delicate herbal infusions. You can find our herbal blends for women with endometriosis here here.
- Taking care of sleep. Sleep deprivation exacerbates intestinal problems, and the appropriate amount and quality of sleep is essential to see the best results from a low FODMAP diet.
- Regular physical activity. Walking, yoga, cycling, swimming, and dancing are all activities that positively impact gut function and the nervous system. You can read more about this in our article. "What exercises should I do with endometriosis?"
Side effects of the low fodmap diet
The low-FODMAP diet, especially the first elimination phase, should be followed for a maximum of several weeks. Prolonging it may cause a number of problems, such as:
- Nutritional deficiencies, especially iron, calcium, B vitamins,
- Constipation associated with lower consumption of fiber-rich foods,
- Unfavorable changes in the intestinal microbiota, including a reduction in the number of Bifidobacterium bacteria.
The low FODMAP diet should therefore only be used in specific cases, for a specific period of time and according to a specific schedule, and under the supervision of a dietitian.
Summary
A low-FODMAP diet for endometriosis is particularly recommended and effective for patients with irritable bowel syndrome (IBS) and/or small intestinal bacterial overgrowth (SIBO). Limiting foods rich in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols helps reduce digestive symptoms such as abdominal pain, bloating, gas, and diarrhea. This can significantly improve quality of life and daily comfort. A low-FODMAP diet should be guided by a dietitian and tailored to the individual patient to avoid nutritional deficiencies and adverse changes in the gut microbiota.
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Aleksandra Dziura
A clinical dietitian, she graduated from the Medical University of Warsaw (undergraduate and graduate studies) and the Institute of Performance Nutrition. She continually expands her knowledge of women's health and nutrition by participating in conferences in Poland and abroad. She takes a holistic approach to working with patients, seeking the root cause of problems rather than simply masking symptoms. For over five years, she has been working with women with endometriosis and adenomyosis.